CUSTOMER IDENTIFICATION FORM

(USA Patriot Act Section 326)

 

Borrower’s Name: ____________________________________________

 

Residential Street Address:_____________________________________________________

To help the government fight the funding of terrorism and money laundering activities, Federal law requires us to obtain, verify, and record information that identifies each person who applies for financial services from The Fuller Center for Housing.  We will ask for your name, address and other information that will allow us to identify you.  We may also ask to see your driver’s license or other identifying documents.

For persons without a SSN/TIN, the ID number must be from one of the following: passport, alien ID card, or any other government issued document issued document evidencing nationality or residence and bearing a photograph or similar safeguard.  At least two forms of identification must be presented and documented. For applications taken in person, at least one “Primary” form of ID must be used. For all other applications, any combination of Primary and Secondary Ids may be used. Complete a separate form for each Borrower.

 

Primary Forms of ID – must display Borrower’s Name Document Country/State of Origin

 

ID Number___________________________________________

Date of Birth__________________________________________

Expiration____________________________________________

Date________________________________________________

 

[ ] State Issued Driver License

[ ] State Issued ID Card

[ ] Military ID Card

[ ] Passport

[ ] US Alien Registration Card

[ ] Canadian Driver License

 

Secondary Forms of ID – must display Borrower’s Name

 

ID Number___________________________________________

Date of Birth__________________________________________

Expiration____________________________________________

Date________________________________________________

 

[ ] Social Security Card U.S. Government

[ ] Government Issued Visa

[ ] Birth Certificate

[ ] Non-US/Canadian Driver License

[ ] Most Recent Signed Tax Returns [ ] Fed [ ] State

[ ] Voter Registration Card

[ ] Organizational Membership Card

[ ] Bank/Investment/Loan Statements

[ ] Paycheck stub with name

[ ] Most Recent W-2

[ ] Home/car/renter insurance papers

[ ] Recent utility bill

 

I certify that I have personally viewed and accurately recorded the information from the documents identified above, and have reasonably confirmed the identity of the applicant.

 

Fuller Center Representative Signature: ________________________________________

Date: ______________________

Fuller Center Representative Name: ____________________________________________